REVIEWS

MOLECULAR AND NEURONAL

SUBSTRATES FOR GENERAL
ANAESTHETICS
Uwe Rudolph* and Bernd Antkowiak ‡
Abstract | Although general anaesthesia has been of tremendous importance for the
development of surgery, the underlying mechanisms by which this state is achieved are only just
beginning to be understood in detail. In this review, we describe the neuronal systems that are
thought to be involved in mediating clinically relevant actions of general anaesthetics, and we go
on to discuss how the function of individual drug targets, in particular GABAA-receptor subtypes,
can be revealed by genetic studies in vivo.

BENZODIAZEPINES
Pharmacologically active
molecules with sedative,
anxiolytic and anticonvulsant
effects. They act by binding to
the GABA receptor and
potentiate the response elicited
by the transmitter.
*Institute of Pharmacology
and Toxicology, University of
Zürich, Winterthurerstrasse
190, CH-8057 Zürich,
Switzerland. ‡Department
of Anaesthesiology,
Section of Experimental
Anaesthesiology,
University of Tübingen,
Schaffhausenstr. 113,
D-72072 Tübingen,
Germany.
Correspondence to U.R.
e-mail:
rudolph@pharma.unizh.ch
doi:10.1038/nrn1496
General anaesthetic agents are used widely, both in
clinical medicine and in neuroscience research. In the
operating theatre, general anaesthesia provides pain
relief, immobility and unconsciousness. In neuro-
science research, anaesthetic agents have been used to
identify neuronal substrates that are involved in con-
scious perception1, to explain neural mechanisms of
sleep and arousal2 and to investigate the cortical cir-
cuits that produce rhythmic population activity3,4.
Therefore, understanding the molecular basis of the
action of general anaesthetics is crucial for several areas
of neuroscience.
In 1846, William T. Morton made a breakthrough in
medical science when he demonstrated — in the ‘Ether
Dome’ of the Massachusetts General Hospital in Boston
— that a patient who had been anaesthetized with ether
did not experience pain during the removal of a tumour
from his neck. Two years earlier, H. Wells in Connecticut
had recognized the anaesthetic properties of laughing
gas (nitrous oxide), and in 1847, J. Simpson in
Edinburgh had introduced chloroform into medical
practice. Since that pioneering time, anaesthetic practice
has changed significantly, in that general anaesthesia is
rarely achieved by a single agent but by a combination of
general anaesthetics and other agents such as muscle
relaxants, analgesics and sedatives5. Nevertheless, experts
still define general anaesthetics by their capacity to pro-
duce a state in which surgery can be tolerated without
the need for further drugs6.
Recently, considerable progress has been made in
understanding how general anaesthetics affect CNS
function. Here we attempt to integrate the latest insights
from behavioural, imaging, electrophysiological and
genetic studies. We focus on modern intravenous
anaesthetics, in particular, propofol, etomidate and
BENZODIAZEPINES. For recent comprehensive reviews on
volatile anaesthetics, see REFS 5,7.
Molecular actions: the long and winding road
By 1850, several structurally unrelated volatile com-
pounds, including ether, chloroform and nitrous oxide,
were known to possess analgesic and anaesthetic
properties. Claude Bernard proposed that these agents
act through a common molecular mechanism8.
Intravenous anaesthetics, such as pentobarbital and
thiopental, were introduced approximately 80 years
later. The chemical structures of some volatile and
intravenous anaesthetic agents that are in current use
are shown in FIG. 1.
At around 1900, Meyer and Overton independently
discovered a strong correlation between anaesthetic
potency and solubility in oil9,10. This finding prompted
the lipid theory, which states that general anaesthetics
act through a common and nonspecific mechanism by
dissolving in the membrane of nerve cells, thereby caus-
ing structural changes in the lipid bilayer. However, in a
series of seminal investigations, Franks and Lieb showed
that general anaesthetics in fact interact directly with

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Intravenous general anaesthesia arise from the effects of a single drug

Thiopental (~25 µM) Propofol (~1.2 µM) Etomidate (~1.5 µM) in different parts of the CNS18–20, and it is now widely
H accepted that general anaesthetics cause immobility by
O N S OH
2
H C
3
HC depressing spinal neurons, and amnesia and hypnosis
H5C2 (H3C)2CH CH(CH3)2
5 NH H5C2 O C
N by acting on neurons in the brain5,7. In a series of recent
H3C CH2 CH2 HC
O O N
studies using functional neuroimaging and electro-
CH3 physiological techniques, interesting insights were
gained into the mechanisms that underlie the modulation
Volatile of human brain activity by propofol (FIG. 2). The behav-
Isoflurane (~320 µM) Sevoflurane (~350 µM) Nitrous oxide (~15 mM)
ioural actions of propofol cover a large concentration
F H F N N O
F H F range — high concentrations produce deep sedation,
F C C C F
F C C O C H hypnosis and immobility, whereas mild sedation and
F O F
F Cl F impairment of memory performance occurs at lower
H C H
concentrations (around 3% of those needed to induce
F
immobility)21,22. In the sections that follow, we discuss
Figure 1 | Structural formulae of anaesthetic agents in current clinical use. The how brain activity is altered by different doses of propo-
barbiturate thiopental was introduced around 1935, and etomidate and propofol became fol and other anaesthetic agents to produce the various
available 40 years later. Isoflurane and sevoflurane are halogenated ethers that have been used components of the anaesthetic state.
since 1970 and 1980, respectively. Nitrous oxide (laughing gas) has been known since the
pioneering time of general anaesthesia in the mid-nineteenth century. These anaesthetic agents
Sedation and hypnosis (unconsciousness). Hypnosis is
differ in potency, and the estimated effective concentrations that produce immobility in half the
patients are given in brackets12,22,47. Note that nitrous oxide and propofol differ in potency by a
commonly defined as drug-induced impairment of the
factor of 10,000. cognitive functions that are required for responding
adequately to environmental stimuli5. In clinical
settings, patients are assumed to be unconscious if they
proteins11. Furthermore, OPTICAL ISOMERS of several fail to respond to verbal commands or mild shaking.
anaesthetic agents differ in potency, which is not The terms sedation and hypnosis are sometimes used as
explained by a nonspecific action12, and perturbations synonyms23, but there is accumulating evidence that
in lipids that result from changes in temperature do not they reflect states that can be distinguished by the pattern
produce anaesthesia, as would be predicted from the of brain areas that is impaired. At sedative concentra-
lipid theory of anaesthetic action13. In addition, some tions, propofol reduces neuronal activity prominently in
exceptions to the Meyer–Overton rule have been iden- cortical networks. At higher, hypnotic concentrations,
tified, such as ‘non-immobilizers’, which do not ablate subcortical structures, including the thalamus, midbrain
motor reflexes even though they would be predicted reticular formation and possibly the hypothalamus, are
to do so according to the Meyer–Overton rule owing to also affected. Interestingly, there is a linear relationship
their chemical properties14, and the ‘long-chain alcohol between the regional metabolic reductions that occur
cut-off ’ — the finding that alcohols that exceed a during propofol-induced hypnosis in humans and the
certain size are inactive15,16. Because of these and further known regional benzodiazepine binding site densities,
experimental findings that were not compatible with a consistent with a similar mechanism of action of
nonspecific action within lipid films, the lipid theory propofol and benzodiazepines24. Dose-dependent
fell out of favour. enhancement of [11C]-flumazenil binding by isoflurane
In the past few decades, research on anaesthetic provides support for the idea that this receptor might
mechanisms has mainly focused on ion channels that also be involved in mediating the effects of some volatile
OPTICAL ISOMERS are located in the membrane of nerve cells. At clinically anaesthetics25. However, the pattern of depressed brain
Also known as chiral molecules, relevant concentrations, general anaesthetics alter the areas varies between propofol and isoflurane, indicating
optical isomers are molecules
discharge properties of central neurons, leaving axonal that they act on different molecular targets.
that are exact non-
superimposable mirror images conductance of action potentials largely unaffected. A During propofol-induced hypnosis, global cerebral
of one another. recent review lists more than 30 types of ion channel blood flow and glucose metabolism seem to be signifi-
that have been found to be affected within this concen- cantly decreased, and some brain areas show a markedly
ELECTROENCEPHALOGRAPHY tration range5. However, it is still unclear which of these higher degree of depression than others. These regions
(EEG). A technique used to
measure neural activity by
molecular targets are most relevant for mediating are localized in diverse cortical areas, and also in the thal-
monitoring electrical signals clinically desired actions, and which are responsible for amus and midbrain1,26. Similar to propofol, the benzodi-
from the brain that reach the unwanted side effects. azepines midazolam and lorazepam produced a large
scalp. EEG has good temporal decrease in thalamic regional cerebral blood flow (rCBF)
resolution but relatively poor
Neuroanatomical substrates for anaesthetics during deep sedation 27. Evidence that thalamic struc-
spatial resolution.
The essential goals of the anaesthetic state are immobility, tures are inhibited at hypnotic propofol concentrations
ALPHA POWER unconsciousness and amnesia (lack of memory of the has also been provided by ELECTROENCEPHALOGRAPHY (EEG).
Rhythmic neural activity with a surgical procedure)17 (BOX 1). The question of where Gugino and co-workers report that at sedative concen-
frequency of 8–12 Hz. anaesthetic agents act in the CNS to produce these trations, propofol and sevoflurane attenuate ALPHA POWER
BETA POWER
specific effects has been addressed only recently. and increase frontal BETA POWER28. With loss of conscious-
Rhythmic neural activity with a Approximately 10 years ago, Kendig, Eger and Kissin put ness, slow-wave activity in the delta band becomes more
frequency of 12–25 Hz. forward the hypothesis that different components of prominent, whereas frontal beta power decreases,

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Box 1 | Components of the anaesthetic state
Amnesia
The partial or complete loss of memory. Memory formation occurs at various sites in
the brain, including the hippocampus, amygdala, prefrontal cortex and other cortical
sensory and motor areas. Patients should be unable to remember what happened during
a surgical procedure. In this context, the possibility of both implicit and explicit
memory formation is relevant. Explicit memory refers to information that is
consciously perceived and retained, and can subsequently be reported. Patients who
accidentally awaken from anaesthesia during surgery frequently suffer from an
unpleasant experience that is recalled for a long time. Implicit memory refers to
information that is unconsciously perceived, and that cannot be reported. Assume that
during surgery a patient has unconsciously perceived the doctor’s first name ‘Robert’.
The word ‘Robert’ becomes associated with a harmful experience and is loaded with
negative emotions, and after surgery the patient dislikes people called Robert. In this
case, information has been retained that influences the patient’s behaviour but cannot
be recalled. Anaesthetic-induced amnesia usually affects recall of events that occurred
after the onset of anaesthesia (anterograde amnesia).
Sedation
This term refers to a decreased level of arousal, as indicated by long response times,
decreased motor activity and slurred speech. There are various definitions of sedation:
sometimes it is used as a synonym for hypnosis or to indicate incomplete hypnosis.
However, recent studies indicate that the sedative and hypnotic actions of general
anaesthetics are produced by distinct mechanisms, and there is evidence for molecular
targets that specifically mediate sedative drug effects. Sedation has been distinguished
from the amnestic effects of anaesthetics by comparing different drugs at equi-sedative
concentrations.
Hypnosis (unconsciousness)
There are various definitions of hypnosis: the term is frequently used to connote drug-
induced impairment of neural functions that are required to respond to verbal
commands. Conscious perception of environmental stimuli is ablated during hypnosis.
Several theories have been used to explain how anaesthetics might produce hypnosis.
Although overlapping, they emphasize different aspects of the anaesthetic state, such as
similarities between anaesthesia and natural sleep23, depression of neuronal excitability
and activity 29 or the de-integration of cortical information processing 40. In animal
studies, the loss of the righting reflex is used as a marker for the hypnotic state.
Immobility
Lack of movements in response to noxious stimuli.
Further components
There is no common agreement about the essential components that define the
anaesthetic state, and some authors mention further aspects, including myorelaxation
(muscle relaxation), analgesia and anxiolysis6.
indicating a shift from cortical towards subcortical
generator regions. This result is corroborated by the
finding that the decrease in cortical glucose metabolism
THETA POWER during the transition from a sedated to an unconscious
Rhythmic neural activity with a state is accompanied by reduced relative beta, alpha and
frequency of 4–12 Hz. 26
THETA POWER, whereas DELTA POWER is increased . Alkire
DELTA POWER proposed that thalamocortical cells, which have been
Rhythmic neural activity with a identified as the main generators of cortical delta
frequency of 1–4 Hz that is rhythms, are also involved in producing anaesthetic-
characteristic of stage III and IV
induced delta activity29, similar to natural delta sleep.
non-rapid eye movement sleep
(also known as slow-wave sleep). The reasoning is that decreased excitation shifts the
firing mode of thalamic relay neurons from a TONIC to a
TONIC burst pattern, thereby producing delta activity 30.
Physiological events that occur How does propofol affect the processing of sensory
in a sustained manner, unlike
phasic events, which occur only
stimuli in the thalamus? At mildly sedating concentra-
transiently with intervening tions, human subjects’ ratings of thermal pain were
periods of inactivity. increased, and there was a corresponding increase in
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evoked activity in the thalamus and somatosensory
cortex31. When subjects lost consciousness, noxious-
stimuli-evoked thalamic responses were abolished. In a
study that used a similar experimental design, tactile
stimuli were applied during sedative and hypnotic
propofol concentrations32. With sedative doses of propo-
fol, evoked responses were attenuated in the somatosen-
sory cortex only. At hypnotic concentrations of propofol,
thalamic and cortical responses ceased. The conclusion
that propofol-induced loss of consciousness goes along
with impaired thalamic information transfer is also sup-
ported by studies on auditory-evoked potentials, which
indicate that changes in the mid-latency auditory-evoked
potential, which is generated close to the primary audi-
tory cortex, are a good predictor for unresponsiveness33.
Magoun and Moruzzi discovered that several nuclei
in the midbrain reticular formation are involved in
arousal, wakefulness and sleep34, and these structures
are also plausible targets for general anaesthetics to
produce some of their sedative and hypnotic effects.
Fiset and co-workers observed that propofol-induced
depression of thalamic and reticular rCBF are closely
linked1. In the cat, halothane, enflurane and isoflurane
depress spontaneous single-unit firing in the midbrain
reticular formation. Neuronal activity was decreased by
20–30% at hypnotic and by 60–70% at immobilizing
concentrations35. The latter report is consistent with the
finding that volatile anaesthetics decrease acetylcholine
(Ach) levels in the laterodorsal and pedunculopontine
tegmental nucleus36, and Perry and co-workers have
speculated on a central role for cholinergic transmission
in general anaesthesia37. However, blockers of brain
nicotinic and muscarinic Ach receptors have not been
demonstrated to be clinically useful.
Although not identical, sleep and general anaesthesia
share common features, including a similar EEG pattern
and depression of sensory input and motor output.
Furthermore, a recovery process similar to that which
occurs during sleep takes place during anaesthesia38.
So, hypothalamic networks that are involved in sleep
regulation might have a key role in mediating anaes-
thetic-induced hypnosis. The hypnotic effects of several
anaesthetics applied locally to the tuberomammillary
nucleus, a GABA (γ-aminobutyric acid)-modulated
region of the hypothalamus that is involved in the regu-
lation of sleep and wakefulness, are consistent with such
a mechanism23.
Although most general anaesthetics strongly depress
neuronal activity in the thalamocortical system at
hypnotic concentrations, this is not necessarily the most
important mechanism for causing unconsciousness,
because some anaesthetics produce hypnosis without
markedly decreasing neuronal activity39,40. Ketamine
is an example of this type of drug: it does not reduce
cortical metabolism and glutamate release or depress
sensory information flow through the thalamus41–43 (it
should be pointed out, however, that because of its
undesirable psychomimetic properties, including the
recall of intraoperative events, ketamine is not used for
inducing and maintaining hypnosis44). A mechanism
that might explain impairment of cortical functions by
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a b Frontal cortex
Light sedation
Propofol plasma concentration (µg/ml)
10 Moderate sedation
Hypnosis
Immobility
1 MRF
Thalamus
Anaesthetic depth Spinal cord
Figure 2 | Propofol anaesthesia in humans. a | Correlation between propofol plasma
concentration and anaesthetic depth. Symbols indicate values reported in different studies to
cause light and moderate sedation, hypnosis and immobility. Horizontal bars represent mean
values. The immobilizing actions of propofol in the absence of further drugs have been
investigated in only a single study22. b | Sites in the CNS that are thought to be involved in the
sedative, hypnotic and immobilizing actions of propofol. The concentration-dependent
depression of CNS functions by propofol seems to be in accordance with the classic idea that
phylogenetically older parts of the CNS are more resistant to anaesthetic treatment than those
that appeared later in evolution. The sequence illustrated in b might imply that thalamic, brainstem
and spinal neurons are not affected by sedative propofol concentrations. However, this is clearly
not the case. Recent studies have shown that at sedative concentrations, propofol significantly
decreases the excitability of spinal neurons115,116. It must be taken into account that the end
points shown in a are related to different types of neuronal activity. Higher cognitive functions,
such as working memory, which are affected by sedative propofol concentrations, arise from
interactions within large neuronal populations located in different cortical and subcortical areas.
This type of distributed network activity might be particularly sensitive to anaesthetic treatment, as
actions that seem to be small at the level of a single synapse multiply117. The situation is different
when considering the immobilizing effects of anaesthetics: to ablate movements, a powerful
excitatory drive onto spinal neurons, produced by noxious stimulation, has to be depressed by
drug treatment. To suppress this massive excitatory input, a high degree of neuronal inhibition,
and consequently a high anaesthetic concentration, is required. MRF, midbrain reticular
formation. Anatomical image adapted, with permission, from REF. 118  (1996) Appleton & Lange.
anaesthetic agents without assuming a sleep-like state or
a strong depression of neuronal activity is ‘cognitive
unbinding’40. The binding problem refers to the question
of how a unified experience arises from the well-known
division of labour in the brain45, and the term binding
denotes the process of bringing together different
aspects of an object or event, such as shape, colour and
movement. There is probably no single location in the
brain where all features of a consciously perceived
object/event all come together. Rather, a unified experi-
ence is represented by a temporal coalition of neurons
located in distinct cortical areas. One possible solution is
synchrony: neurons that represent the same object/event
are active at the same time. In particular, high-frequency
cortical GAMMA OSCILLATIONS are suggested to have an
important role in cognitive binding, and a rostrocaudal
dissociation of synchronized gamma oscillations has
been reported during anaesthesia46. Furthermore, the
hemispheres themselves become functionally discon-
nected. So, anaesthetics might abolish the capacity
of cortical circuits to build up complex population
activities that represent unified experiences.
GAMMA OSCILLATIONS
Another line of evidence to indicate that direct
Rhythmic neural activity with a anaesthetic actions on cortical neurons are involved
frequency of 25–70 Hz. in the hypnotic state comes from in vitro studies
712 | SEPTEMBER 2004 | VOLUME 5
on isolated cortical networks. These investigations
demonstrated that the slowing of oscillatory activity in
the gamma47 and theta/delta4 range can be elicited by
anaesthetics in the absence of subcortical structures,
including the thalamus and midbrain. Furthermore,
evidence was provided that at sedative and hypnotic
concentrations, several anaesthetic agents profoundly
decrease ongoing neuronal activity in isolated cortical
networks48.
Amnesia. Functional imaging studies, in which human
subjects were asked to memorize words during adminis-
tration of propofol, identified neuroanatomical sub-
strates that are relevant for the modulation of working
memory by general anaesthetics21. Propofol causes simi-
lar concentration-dependent depressions of rCBF and
oxidative metabolism in the brain, so it is reasonable to
assume that the propofol-induced depression in rCBF is
closely linked to a depression in neuronal activity 49. At
mildly sedating concentrations (0.5 µg/ml), propofol
decreased rCBF in right-sided prefrontal and parietal
regions, close to the areas that were activated in the base-
line memory task. By contrast, even heavy propofol
sedation (2 µg/ml) did not affect the enhancement of
rCBF in the primary auditory cortex that was associated
with an increase in the word presentation rate. These
differential sensitivities of cortical networks indicate that
the sedative and amnesic effects of propofol do not
result from a general and nonspecific depression of
neuronal excitability. Recently, this conclusion was
confirmed in studies of auditory-evoked potentials,
which showed that higher cognitive functions that are
processed in the frontal cortex are more sensitive
to propofol sedation than event-related potentials
generated in or in the vicinity of the primary auditory
cortex50. Taken together, there is compelling evidence
that during propofol sedation, higher cognitive func-
tions are impaired, whereas early cortical sensory
processing remains functional.
Do low concentrations of volatile anaesthetics have
a similar effect? In a functional magnetic resonance
study, Heinke and Schwarzbauer investigated the
actions of isoflurane on human subjects performing a
visual task51. At concentrations that caused moderate
sedation, subcortical areas and cortical regions that are
involved in early visual information processing
remained unaffected, whereas task-related activation of
cortical areas that process higher cognitive functions
was depressed. Studies on monkeys to investigate
the effects of isoflurane in the visual system produced
similar results52,53: at sedative concentrations, isoflurane
did not alter visual evoked responses of neurons in the
primary cortex, whereas the higher-order processing
that is responsible for integrating local signals into a
global visual representation was markedly disturbed.
Immobility. Several lines of evidence indicate that anaes-
thetic-induced ablation of movements in response to a
noxious stimulus is mediated primarily by the spinal
cord54. For example, in rats, transection of the upper
thoracic spinal cord or precollicular decerebration only
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Box 2 | Effects of general anaesthetics on ligand-gated ion channels
GABAA Glycine nACh nACh 5-HT3 AMPA Kainate NMDA
receptor receptor (muscle) (neuro) receptor receptor receptor receptor
receptor receptor
Etomidate
Propofol
Barbiturates
Ketamine
Isoflurane
Sevoflurane
Nitrous oxide
Ligand-gated ion channels are thought to be among the most relevant targets for
general anesthetics, and the modulatory activity of general anaesthetics on these
channels has been studied in vitro. In the figure, a dark green or pink spot indicates
significant potentiation or inhibition, respectively, of agonist actions at the receptor by
the anaesthetic with an EC50 or IC50 that is no greater than three times higher than the
EC50 for producing immobility; a light green or light pink spot indicates little
potentiation or inhibition, respectively, at concentrations that were less than three
times the EC50 for immobility; an empty spot indicates no effect at any concentration
tested. The data are from REFS 107,110.
It should be noted that for many ligand-gated ion channels, there are multiple subtypes
that might differ in their functional properties, so this presentation represents a vast
oversimplification. Furthermore, equipotent anaesthetic doses were not necessarily used
in the various studies summarized in this figure, making comparisons difficult and the
rating within the classification scheme arbitrary. The results might depend on specific
experimental conditions, and there might be conflicting reports. For example, in the case
of nitrous oxide, some reports indicate a potentiation of GABAA (γ-aminobutyric acid,
type A) receptors111,112, whereas other papers report no effect or only a mild effect113,114.
The figure shows that all general anaesthetics interact with multiple targets, and with the
potential exceptions of isoflurane and sevoflurane, each drug has a unique pattern. At
present, it is largely unknown which behavioural action of which anaesthetic is caused by
which ligand-gated ion channel. AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazole
propionic acid; 5-HT3, 5-hydroxytryptamine, type 3; nACh, acetylcholine receptor
(nicotinic subtype); NMDA, N-methyl-D-aspartate receptors.
minimally affected the capacity of volatile anaesthetics
to depress movements55,56. Furthermore, delivery of
anaesthetic drugs specifically to the brain as opposed to
the spinal cord increased the concentration that was
needed to suppress noxious-stimuli-induced move-
ments by three–fourfold54,57. Also, immobility correlates
with a suppression of motor-neuron excitability, as
probed by recurrent impulses known as F-waves in
humans58. Interestingly, general anaesthetics depress the
transmission of noxious stimuli from the spinal cord to
the brain, thereby decreasing supraspinal arousal59.
EC50
The concentration of an agent Therefore, the action of anaesthetics at the spinal level
that provides a half-maximal contributes to the slowing of EEG activity, which indi-
activation of a target in vitro. cates that the spinal actions of general anaesthetics
influence sedative and hypnotic effects. Conversely,
IC50
The concentration of an agent
there is evidence that descending signals from the brain
that provides a half-maximal to the spinal cord modify the immobilizing effects of
inhibition of a target in vitro. general anaesthetics60.
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For volatile anaesthetics, the minimal alveolar
concentration (MAC) concept was devised as a standard
measure for anaesthetic potency61. The MAC is defined
as the concentration (in % atmospheres) of inhalational
anaesthetics that is required to blunt the muscular
response to surgical skin incision of 50% of a population
of unparalyzed patients or animals. So, the MAC is
an anaesthetic 50%-effective dose (ED50) in vivo.
Using partition coefficients, the corresponding blood
concentrations have been estimated (FIG. 1).
The variable effects of different anaesthetic agents in
the spinal cord are not compatible with a common
cellular and molecular mechanism of action. For
instance, there is ample evidence that halothane reduces
noxious-evoked movement through the depression of
dorsal horn neurons, whereas isoflurane suppresses
movements by acting at more ventral sites62. The pres-
ence of multiple molecular targets in the spinal cord
might explain why isoflurane, despite having potent
effects on GABAA (GABA type A) receptors in vitro,
seems to exert its immobility either completely or at
least in large part through different mechanisms, as
determined by the blockade of the GABAA receptors
with picrotoxin63. It is also interesting to note that intra-
venous and volatile anaesthetics seem to decrease spinal
excitability through different molecular mechanisms —
in vivo and in vitro studies indicate that propofol and
etomidate act primarily by enhancing GABAA-receptor-
mediated inhibition, whereas volatile anaesthetics act
through glycine (Gly) receptors and further targets7.
Pathways of anaesthetic action
Although it is generally accepted that anaesthetic-
induced depression of movements is predominantly
produced in the spinal cord, whereas sedation, amnesia
and hypnosis are related to anaesthetic actions in the
brain, the idea of a common end point is generating
considerable interest. Alkire proposed that the direct or
indirect depression of thalamocortical neurons provides
a convergence point for pathways of anaesthetic action,
leading to a sleep-like state29. However, it is also plausible
that anaesthetic-induced changes in the thalamocortical
system during loss of consciousness are caused by actions
on hypothalamic nuclei23. As outlined above, some
authors favour a cortical mechanism for anaesthetic-
induced unconsciousness, working on the assumption
that cognitive unbinding is the common end point.
At present, the relative contributions of each of these
putative mechanisms to the generation of the hypnotic
state are unknown. To test the various hypotheses, it
would be useful to have drugs that act selectively on
thalamic, hypothalamic or cortical neurons. However,
such drugs are not currently available. An alternative
approach is to use animal models in which the mole-
cular targets of anaesthetic agents are either lacking
or are rendered insensitive to general anaesthetics.
There is a long list of molecular targets, the activity of
which is mediated by at least one general anaesthetic.
These include ligand-gated ion channels, such as
GABAA receptors, Gly receptors, nicotinic Ach recep-
tors, 5-HT3 (5-hydroxytryptamine, type 3) receptors,
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a b Inhibitory postsynaptic current Most functional GABAA receptors in the CNS seem
to contain at least α- and β-subunits, plus a γ- or δ-
subunit. GABAA receptors that contain the γ-subunit

Current
+ Anaesthetic
GABA
Time Control
c tically (FIG. 3). In vitro, the δ-containing receptors are
β approximately 3 times more sensitive to ethanol than
α α
Cl – β γ
Cl –
–
– – –– –
– – Cl – – – Cl – –
– – – – – – –
– –– – –
Figure 3 | Synaptic and extrasynaptic locations of GABAA receptors. a | On binding of
GABA (γ-aminobutyric acid; yellow dots) to the pentameric GABAA receptor complexes, chloride
flows into the postsynaptic neuron, leading to hyperpolarization. Synaptic GABAA receptors (pink)
have a low potency and a high efficacy, whereas extrasynaptic GABAA receptors (blue) have a
high potency and a low efficacy. GABAA receptors that contain the δ- and the β3 subunit, which
are located extrasynaptically, have an increased sensitivity to ethanol in vitro, and it has been
suggested that they might be important targets for general anaesthetics70. b | General
anaesthetics prolong channel opening and increase postsynaptic inhibition. c | A pentameric
GABAA receptor complex in the lipid bilayer membrane.
AMPA (α-amino-3-hydroxy-5-methyl-4-isoxazole
propionic acid), kainate and NMDA (N-methyl-D-
aspartate) receptors64 (see also BOX 2). Most of these
receptor types are heterogeneous, and only selected
subtypes might be sensitive to general anaesthetics.
Furthermore, two-pore-domain potassium channels are
modulated by some volatile general anesthetics65.
In recent years, the GABAA-receptor system has
attracted considerable attention as a target for benzo-
diazepines and also, as mentioned above, for general
anaesthetic agents. The great heterogeneity of GABAA
receptors, which will be reviewed in the next section,
has long precluded the attribution of physiological and
pharmacological functions to specific GABAA-receptor
subtypes. However, using knock-in point mutations in
mice, two independent groups have recently provided
definitive evidence that specific GABAA-receptor
subtypes are involved in the actions of etomidate66,67
and propofol66.
are mostly at synaptic locations, but can also occur at
extrasynaptic locations, whereas GABAA receptors that
contain the δ-subunit are typically located extrasynap-
the γ2-containing receptors, with β3 conferring a
10-fold higher sensitivity than β2 (REF. 70). GABAΑ
receptors are classified either on the basis of their
α-subunit or their β-subunit, which show a differential
distribution in various brain regions71–74.
Anaesthetic action in GABAA-receptor knockout mice.
The effects of general anaesthetics have been studied in
several GABAA-receptor knockout mice. For various
reasons, which might include compensatory regula-
tions, influence on the expression of neighbouring
genes owing to enhancers in the neomycin expression
cassette or multiple impairments, this approach has
met with variable success (reviewed in REF. 75).
However, in δ-subunit knockout mice, the loss of the
righting reflex was significantly increased in response
to the neuroactive steroid alphaxalone and the neuro-
steroid pregnenolone, but not in response to pentobar-
bital, propofol, midazolam, etomidate and ketamine76,
pointing to a potential involvement of (presumably)
extrasynaptic δ-containing GABAA receptors in the
actions of neurosteroidal anaesthetics. In β3-knockout
mice, the duration of the loss of the righting reflex
in response to midazolam and etomidate, but not
to pentobarbital, ethanol, enflurane and halothane, was
reduced compared with the wild type, and the immobi-
lizing action of enflurane and halothane, as determined
in a TAIL CLAMP/WITHDRAWAL ASSAY, was decreased. These
findings indicate a role for β3-containing GABAA
receptors in mediating, in part, the hypnotic action of
midazolam and etomidate, and, also in part, the
immobilizing action of enflurane and halothane77. It
should however be kept in mind that when depression
of spinal cord neurotransmission induced by enflurane
was examined in sections from these mice, it was
found that other targets substitute for the role that is
normally played by β3-containing GABAA receptors78.

TAIL CLAMP/WITHDRAWAL
ASSAY
An assay in which motor activity
is measured in response to a tail-
clamp stimulus.
GABAA receptors and general anaesthetics
GABAA-receptor heterogeneity. GABAA receptors are
involved in the regulation of vigilance, anxiety, muscle
tension and memory performance. They are pentameric
complexes, and six α, three β, three γ, one δ, one ε, one π
and three ρ-subunits have been identified so far.
Despite this multitude of subunits, certain combina-
tions are preferred: for example, more than 60% of
all GABAA receptors in the brain are of the α1β2γ2 com-
position, about 15% consist of α2β3γ2 and about
10–15% consist of α3βnγ2. The subunit combinations
α4β2γ/α4βnδ, α5β1/3γ2, α6β2/3γ2 and α6βnδ each
represent less than 5% of all receptors in the brain68,69. In
cases in which α-, β- and γ-subunits are co-assembled,
it is believed that the stoichiometry α:β:γ is 2:2:1.
Using point mutations to study anaesthetic actions.
In pioneering studies using mutated recombinant
receptors, several groups79–81 identified amino-acid
residues in the second and third transmembrane
region of α- and β-subunits that are crucial for the
action of many general anaesthetics on recombinant
GABAA receptors. Whereas sites on both α- and
β-subunits are crucial for volatile anaesthetic action79
(for example, α1-S270, α1-A291, β2-N265 and β2-
M286), only the sites on the β-subunit have been
found to be relevant for the action of the intravenous
anaesthetics propofol and etomidate 80,81. It was later
shown in recombinant α1β2γ2 and α2β3γ2 receptors
that the replacement of asparagine 265 with a methio-
nine (Met) in the β2 or β3 subunit (Met is the residue

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Wild type β2, β3 β2(N265S) β3(N265M)
NH2 NH2 NH2
S S S
S S S
Extracellular
Asn COOH Ser COOH Met COOH
Intracellular
Propofol: ++ Propofol: ++ Propofol: 0
Etomidate: ++ Etomidate: 0/(+) Etomidate: 0
Figure 4 | Amino-acid point mutations in β2(N265S) mice and β3(N265M) mice. The wild-
type β2 and β3 subunits have an asparagine (Asn) residue at position 265 in the second
transmembrane region. GABAA (γ-aminobutyric acid, type A) receptors that contain these subunits
are sensitive to propofol and etomidate. In β2(N265S) mice, the Asn is changed to serine (Ser), the
residue that appears at this site in the β1 subunit67. Receptors that contain this mutation are largely
insensitive to etomidate, but are sensitive to propofol. In β3(N265M) mice, the Asn is replaced by a
methionine (Met), which occurs in the corresponding position of the Drosophila melanogaster RDL
receptor 66. These receptors are insensitive to etomidate and propofol.
at the homologous position in the Drosophila
melanogaster Rdl GABAA receptor, which is insensitive
to etomidate82) resulted in a profound decrease in
the modulatory actions of etomidate, propofol and
enflurane, and in the direct (agonist) actions of
etomidate and propofol83,84. It is unclear whether this
and other relevant residues form a binding site for
general anaesthetics, or whether substitutions of these
residues result in an alteration of the receptor confor-
mation that prevents transduction of the effects of
general anaesthetics.
The demonstration of binding sites for volatile
anaesthetics is hampered by the low affinity of these
substances for neurotransmitter receptors, whereas the
lack of availability of radioactively labelled propofol and
etomidate has largely prevented classic binding studies
for these substances. However, a derivative of etomidate
that is suitable for photolabelling has recently been
developed85.
Anaesthetic actions in knock-in mice
The most fruitful approach for assessing the role of an
individual target in mediating general anaesthetic actions
seems to be the study of mice carrying point mutations
that render the respective target insensitive to defined
KNOCK-IN TRANSGENIC anaesthetic drugs. Ideally, these mutations would not alter
APPROACH the physiological function of the mutated receptor. This
The insertion of a mutant gene
at the exact site of the genome
strategy should minimize compensatory effects, and has
where the corresponding wild- been successfully applied to define the contributions of
type gene is located. This specific GABAA receptors to benzodiazepine actions with
approach is used to ensure that respect to behaviour75 and visual cortical plasticity 86.
the effect of the mutant gene is
By using a KNOCK-IN TRANSGENIC APPROACH to introduce
not affected by the activity of the
endogenous locus. histidine-to-arginine point mutations in position 101 of
the α1 and α2 subunits (mutations denoted α1(H101R)
PRE-PULSE INHIBITION and α2(H101R), respectively), it has been shown that
The ability of a weak pre- the sedative action of benzodiazpines is mediated by
stimulus to inhibit the response
to a stronger stimulus when the
α1-containing GABAA receptors87,88, the anterograde
two stimuli are presented in amnesic action by α1-containing GABAA receptors87 and
quick succession. the anxiolytic-like action of diazepam by α2-containing
NATURE REVIEWS | NEUROSCIENCE
REVIEWS
GABAA receptors89, whereas the myorelaxant action of
diazepam is mediated by α2-, α3- and α5-containing
GABAA receptors90,91.
It is interesting to point out a marked discrepancy in
the conclusions that have been drawn from studies with
α1-subunit mutant mice. The sedative action of
diazepam is lacking in α1(H101R) knock-in mice,
implying that this effect is mediated by α1-containing
GABAA receptors87,88. However, α1-knockout mice were
more sensitive than wild-type mice to the sedative
actions of diazepam92,93. The involvement of α1-
containing GABAA receptors in mediating the sedative
action of diazepam has been confirmed using partially
subtype-selective ligands88. So, on the basis of the
work on the α1-knockout mice alone, an erroneous
conclusion would have been reached.
Analogous to the strategy that was used to analyse
benzodiazepine action, point mutations might be intro-
duced into α-subunit genes that would render the
respective GABAA receptors — predicted from in vitro
data — insensitive to anaesthetics such as halothane
and/or isoflurane81,94. An alternative approach is to
introduce mutations into the β-subunits. Only muta-
tions in the β-subunits are expected to render the
receptors insensitive to the intravenous anaesthetics
etomidate and propofol, and in addition, these mutated
receptors would be expected to have a significantly
reduced sensitivity to enflurane83,84.
Although the action of etomidate is sometimes
considered to be restricted to GABAA receptors that
contain the β2 or the β3 subunit, it has long been
known that etomidate also suppresses the enzyme 11β-
hydroxylase, which is involved in steroid biosynthesis, in
the adrenal cortex95. This suppression is associated with
increased mortality in severely ill patients, and for this
reason, this agent is used only for general anaesthesia of
short duration. Furthermore, it has recently been shown
that etomidate is also an agonist at α2-adrenergic
receptors. Etomidate increases arterial blood pressure in
wild-type mice, but it does not affect blood pressure
in α2B- and α2AB-knockout mice, indicating that this
rise in blood pressure is mediated by the α2B-receptor
subtype96. The affinities of etomidate to the α2B and the
α2C receptors are similar, and they are approximately
4–7 times higher than the affinity of etomidate to the
α2A receptor96. As the effects on the α2B-adrenergic
receptor are observed at a non-immobilizing intra-
venous dose of 2 mg/kg, it is conceivable that at anaes-
thetic doses, etomidate exerts other actions on the CNS
through the α2C- and possibly also the α2A-adrenergic
receptor. The α2C receptor is expressed in various brain
regions, and it has been found to modulate the acoustic
startle reflex, PRE-PULSE INHIBITION and aggression97. In
α2A-knockout mice, the hypnotic effect of etomidate
was indistinguishable from the wild type96, indicating
that this effect is not mediated by the α2A receptor.
Interestingly, the α2A receptor mediates the sedative,
analgesic and anaesthetic-sparing responses of the α2-
agonist dexmedetomidine98. The potency of etomidate
at β1-containing GABAA receptors is reduced by around
a factor of 10 compared with β2- or β3-containing
VOLUME 5 | SEPTEMBER 2004 | 7 1 5
REVIEWS
TETRODOTOXIN
A potent marine neurotoxin that
blocks voltage-gated sodium
channels. Tetrodotoxin was
originally isolated from the
tetraodon pufferfish, and
contains a positively charged
guanidinium group and a
pyrimidine ring.
PLATEAU POTENTIAL
A stable membrane potential
that is more depolarized than
the resting potential. The term
derives from the ‘plateau phase’
of the action potential.
716 | SEPTEMBER 2004 | VOLUME 5
a Righting reflex c
60 20 60 60
Loss of reflex (min)
Loss of reflex (min)
Loss of reflex (min)
Loss of reflex (min)
15
40 40 40
10
20 20 20
5
0 0 0 0
5 10 15 10 20 30 40 6 15 30 5 10 15
Etomidate (mg/kg) Propofol (mg/kg) Alphaxolone (mg/kg) Etomidate (mg/kg)
Wild type β3(N265M) β2(N265S)
b Hindlimb-withdrawal reflex d
15 10 15 10
Loss of reflex (min)
Loss of reflex (min)
Loss of reflex (min)
Loss of reflex (min)
8 8
10 10
6 6
4 4
5 5
2 2
0 0 0 0
5 10 15 10 20 30 40 6 15 30 5 10 15
Etomidate (mg/kg) Propofol (mg/kg) Alphaxolone (mg/kg) Etomidate (mg/kg)
Figure 5 | Behavioural responses to intravenous anaesthetics in β3(N265M) and β2(N265S) mice. Behavioural responses
to intravenous anaesthetics in wild-type, β3(N265M) mice (panels a,b) and β2(N265S) mice (panels c,d). a,b | In wild-type mice
(green bars), the intravenous general anaesthetics etomidate, propofol and alphaxalone/alphadolone elicit a loss of the righting
reflex (a), which is a measure of their hypnotic activity, and a loss of the hindlimb-withdrawal reflex (b), which is a measure of their
immobilizing activity. The duration of the loss of the righting reflex in response to etomidate and propofol is substantially reduced in
β3(N265M) mice, and the hindlimb-withdrawal reflex cannot be elicited at all in the β3(N265M) mice (blue bars). The response to
alphaxalone/alphadolone is indistinguishable in both genotypes. Reproduced with permission from REF. 66 © (2003) The
Federation of American Societies for Experimental Biology. c,d | In β2(N265S) mice (pink bars), the duration of the loss of the
righting reflex in response to etomidate is decreased compared with wild-type mice (c). Etomidate induces a loss of the pedal
withdrawal reflex in β2(N265S) mice (d) (in contrast to what was observed for β3(N265M) mice), although the response was of
shorter duration than in wild-type mice. Data from REF. 67.
receptors (EC50 = 10.8 ± 1.1 µM for α1β1γ2 versus EC50 inhibition of L-type calcium channels could contribute
= 1.2 ± 0.1 µM for α1β2γ2)99. Although β2- and to the reduction of spinal sensorimotor activity during
β3-containing GABAA receptors seem to be the prime anaesthesia. Although propofol has higher EC50 or IC50
targets for etomidate, it cannot be excluded that values at these targets compared with the EC50 value at
β1-containing GABAA receptors also mediate clinically GABAA receptors, it cannot be excluded on the basis of
detectable actions of the drug. As numerous known and EC50 or IC50 alone that the modulation of the activity
potentially also unknown targets for etomidate exist, it is of any of these targets contributes to the clinical action of
impossible to conclude from a mutation that does not propofol. The demonstration in vitro that etomidate
significantly alter or abolish certain anaesthetic actions binds to the α2B-adrenergic receptor with an EC50 of 26
of etomidate that another non-mutated gene product is (15–46) µM, but nevertheless mediates an increase in
responsible for the anaesthetic actions of etomidate. blood pressure at small, subanaesthetic doses of etomi-
Similar considerations apply to propofol. date in vivo, indicates that even a target to which a drug
In vitro, several molecules have been identified that has a much lower affinity than to the GABAA receptor
have their activity modulated by propofol, including (modulatory EC50 = 1.2 ± 0.1 µM for α1β2γ2 recep-
β1- (in apparent contrast to etomidate), β2- and tors99) might contribute to clinically detectable effects of
β3-containing GABAA receptors82,100 (EC50 = 3.8 ± 0.2 the drug. An unambiguous identification of the phar-
µM at α1β2γ2L receptors101, 2.3 ± 0.2 µM for α1β1γ2L macological role of any of these targets in etomidate
GABAA receptors102 and 8.7 ± 0.5 µM at α6β3γ2L recep- action has not been possible so far. These examples also
tors82), the strychnine-sensitive Gly receptors (EC50 = 16 show that the traditional criterion, which states that
± 3 µM for glyine α1 receptors, 27 ± 2 µM for Gly α1β a general anaesthetic must alter the function of the
receptors), voltage-dependent potassium channels (IC50 receptor or ion channel in vitro at clinically relevant
= 43.6 ± 2.5 µM)103, sodium channels (IC50 = 11–18 concentrations for this protein to be considered as a
µM)104 and L-type calcium channels. For L-type calcium candidate to mediate the actions of the anaesthetic107,
channels, one study reported an IC50 of 175 (140–220) should be viewed with some caution. It is conceivable
µM, as determined with radioligand binding105. that in vitro measurements might not be indicative
However, when action potentials are blocked with of the in vivo situation owing to the lack of cellular
TETRODOTOXIN in spinal cord motor neurons from adult components that influence the response. Moreover, in
turtles, PLATEAU POTENTIALS mediated by L-type calcium line with the pharmacological concept of a ‘receptor
channels are uncovered, and these plateau potentials are reserve’, a clinically significant effect might be obtained
totally suppressed by 3 µM propofol106, indicating that at a relatively low occupancy of the target.
www.nature.com/reviews/neuro

Drug Target Action
Voltage-dependent Na+ channels
L-type Ca2+ channels ?
Glycine receptor
β1 (GABAA)
Propofol Sedation
β2 (GABAA)
Etomidate Hypnosis, hypothermia
β3 (GABAA)
Immobility
11β-hydroxylase ↓ GC synthesis in adrenal cortex
α2B adrenoceptor ↑ Blood pressure
α2C adrenoceptor ? of the loss of the righting reflex was indistinguishable
Figure 6 | Proposed roles of GABAA-receptor subtypes and other targets in etomidate
and propofol action. GC, glucocorticoids.
Two groups have recently reported the introduction
of point mutations into β-subunits of the GABAA
receptor. The first such paper (published online
in 2002) reports the generation and analysis of
β3(N265M) mice66 (FIG. 4). This point mutation abol-
ished the modulatory and direct effects of etomidate
and propofol in vitro, and substantially reduced
the modulatory actions of enflurane, whereas the
modulatory action of the neuroactive steroid alph-
axalone was preserved83. In cultured neocortical slices,
etomidate and enflurane were significantly less effective
at decreasing spontaneous action-potential firing66. In
hippocampal CA1 pyramidal neurons, the modulatory
action of etomidate was reduced, consistent with the
β3 subunit being the predominant but not exclusive
β-subunit in these cells. At the behavioural level, motor
activity and hot-plate sensitivity were unchanged in the
HINDLIMB-WITHDRAWAL
absence of drugs.
REFLEX To assess the hypnotic and immobilizing actions of
If a mouse’s hindlimbs are etomidate and propofol, the duration of the loss of the
pulled back, the animal finds this righting and HINDLIMB-WITHDRAWAL REFLEXES was exam-
painful, and it reflexively draws
the limbs in towards the body.
ined (FIG. 5). The duration of the loss of the righting
reflex in response to etomidate and propofol was
PURKINJE CELLS reduced in β3(N265M) mice compared with wild-type
Inhibitory neurons in the mice, indicating that the hypnotic activity is mediated
cerebellum that use GABA as
in part by GABAA receptors that contain the β3 sub-
their neurotransmitter. Their cell
bodies are situated beneath the unit and in part by other targets, possibly GABAA
molecular layer, and their receptors that contain the β2 subunit. Most strikingly,
dendrites branch extensively in the loss of the hindlimb-withdrawal reflex was almost
this layer. Their axons project completely absent in the β3(N265M) mice, indicating
into the underlying white
matter, and they provide the
that the immobilizing action of these drugs depends
only output from the cerebellar on GABAA receptors that contain the β3 subunit. As
cortex. previous research has shown that the immobilizing
NATURE REVIEWS | NEUROSCIENCE
REVIEWS
actions of propofol and isoflurane are mediated at the
spinal cord level57,56,108, it is probable that in the case of
propofol the β3-containing GABAA receptors in the
spinal cord mediate this effect. In β3(N265M) mice,
the immobilizing response to enflurane and halothane
was only moderately decreased, indicating that for
these two volatile anaesthetics, targets other than
β3-containing GABAA receptors have an important
role in mediating the immobilizing response. The
effects of the combined neuroactive steroids alph-
axalone and alphadolone were not altered in β3(N265M)
mice, indicating that they respond normally to general
anaesthetics whose effects are not predicted to be
influenced by the mutation.
An asparagine-to-serine point mutation has been
introduced at the homologous position in the gene
that encodes the GABAA-receptor β2 subunit67. This
β2(N265S) mutation substantially reduces the sensitivity
to etomidate80 but not to propofol (FIG. 4). In cerebellar
PURKINJE CELLS of β2(N265S) mice, which predominantly
express α1β2γ2 GABAA receptors, the potentiating
effect of etomidate was severely reduced67. The duration
between wild-type and mutant mice after intraperi-
toneal injection of etomidate, but after intravenous
injection of etomidate, the duration of the loss of the
righting reflex was smaller in β2(N265S) mice than
in wild-type mice (FIG. 5). By contrast, and as predicted
by the nature of the mutation, the duration of the
loss of the righting reflex in response to propofol was
indistinguishable in both genotypes, indicating that the
function of the β2- containing GABAA receptors is well
preserved in β2(N265S) mice. After intravenous injec-
tion of etomidate, a loss of the pedal withdrawal reflex
is observed, which is less pronounced in β2(265S) mice
compared with wild-type mice (FIG. 5). Again, the action
of propofol given intravenously was indistinguishable
between the two genotypes67. The decrease in loco-
motor activity by low doses of etomidate was diminished
and the etomidate-induced impairment of rotarod
performance was absent in β2(N265S) mice, supporting
the idea that the sedative action of low doses of etomi-
date is mediated by β2-containing GABAA receptors67.
The etomidate-induced burst suppression in the EEG
did not differ between β2(N265S) and wild-type
mice67. As the immobilizing action of etomidate (loss of
the pedal withdrawal reflex) is largely intact in the
β2(N265S) mice67, it can be concluded that GABAA
receptors that contain the β2 subunit do not mediate this
action. Although this result is clearly compatible with the
immobilizing action of etomidate being mediated by
GABAA receptors that contain the β3 subunit, studies
on the β2(N265S) animal model67 do not provide
direct evidence for this.
With respect to etomidate, the results outlined above
indicate that the immobilizing action is mediated by
β3-containing GABAA receptors66, whereas the hypnotic
action is mediated by β3- and β2-containing GABAA
receptors66,67 and the sedative action is mediated by
β2-containing receptors.Furthermore, work on the
β3(N265M) mice provided evidence that propofol
VOLUME 5 | SEPTEMBER 2004 | 7 1 7
REVIEWS

exerts its anaesthetic action through the same target as
etomidate66. In addition, β2-containing GABAA recep-
tors mediate a substantial portion of the hypothermic
action of etomidate109. Current knowledge of the roles of
individual targets for the actions of propofol and etomi-
date is summarized in FIG. 6.
The discovery that β2-containing GABAA receptors
mediate the sedative action of etomidate67, and pre-
sumably of propofol, is consistent with the finding that
α1-containing GABAA receptors mediate the sedative
action of diazepam87,88. Both observations, along with
functional imaging studies, are consistent with the
hypothesis that cortical α1β2γ2 GABAA receptors are
responsible for the sedative action of CNS-depressant
drugs. Similarly, the findings that α2-containing GABAA
receptors mediate to a large extent the myorelaxant action
of diazepam90, and that β3-containing GABAA receptors
mediate the immobilizing action of propofol and etomi-
date66, point to an important role for α2β3γ2 GABAA
receptors in spinal neurons for perturbing behavioural
responses that require proper muscle function.
Conclusions and future prospects
In this review, we have summarized accumulating
evidence that different neuronal systems mediate the
diverse actions of general anaesthetics, and that spe-
cific neurotransmitter-receptor subtypes can be linked
to defined parts of the pharmacological spectrum of
these drugs. Which molecular target is important
depends on the specific anaesthetic and the specific
end point. In particular, volatile anaesthetics seem to
function by means of several targets. The analysis of
mice that carry point mutations in neurotransmitter-
receptor subunits, which rather selectively abolish
the action of general anaesthetics, is a powerful tool
to assess the contribution of a specific receptor type to
the behavioural actions of clinically used anaesthetics.
We expect that other genetic techniques, such as
cell-type-specific or region-specific gene knockouts,
will yield important clues to the function of potential
target proteins for general anaesthetics in defined
neuronal populations. The integration of results from
pharmacological, molecular genetic, functional imag-
ing and electrophysiological studies will probably
provide further insights into the mechanisms of action
of this class of drugs, which will be of great importance
both for medicine and basic neuroscience. These
insights might also provide new avenues for the design
of new general anaesthetics with an improved
side-effect profile.

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Acknowledgements
The authors would like to acknowledge the dedicated work of
R. Jurd, M. Arras, S. Lambert and others on the β3(N265M)
mouse model discussed in this review. The work was supported
by the Swiss National Science Foundation (U.R.), the Deutsche
Forschungsgemeinschaft (B.A.) and the Interdisciplinary Center
for Clinical Research (IZKF) Tübingen (B.A.).
Competing interests statement
The authors declare no competing fiancial interests.
Online links
FURTHER INFORMATION
Bernd Antkowiak’s web page: http://www.medizin.uni-
tuebingen.de/kliniken/anaest_kl/abt_anaest/exp_anaest.html
Uwe Rudolph’s web pages:
http://www.unizh.ch/phar/phargen_website/index.html
http://www.neuroscience.unizh.ch/e/groups/rudolph00.htm.
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